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Abstract
Rapid and accurate triage of patients presenting with chest pain to an emergency department (ED) is critical to prevent ED overcrowding and unnecessary resource use in individuals at low risk of acute myocardial infarction (AMI) and to efficiently and effectively guide patients at high risk to definite therapy. The use of biomarkers for rule-out or rule-in of suspected AMI has evolved substantially over the last several decades. Previously well-established biomarkers have been replaced by cardiac troponin (cTn). High-sensitivity cTn (hs-cTn) assays represent the newest generation of cTn assays and offer tremendous advantages, including improved sensitivity and precision. Still, implementation of these assays in the United States lags behind several other areas of the world. Within this educational review, we discuss the evolution of biomarker testing for detection of myocardial injury, address the specifics of hs-cTn assays and their recommended use within triage algorithms, and highlight potential challenges in their use. Ultimately, we focus on implementation strategies for hs-cTn assays, as they are now clearly ready for prime time.
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Affiliation(s)
| | - L Kristin Newby
- Duke Clinical Research Institute, Durham, North Carolina, USA; ,
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Bevins NJ, Chae H, Hubbard JA, Castillo EM, Tolia VM, Daniels LB, Fitzgerald RL. Emergency Department Management of Chest Pain With a High-Sensitivity Troponin-Enabled 0/1-Hour Rule-Out Algorithm. Am J Clin Pathol 2022; 157:774-780. [PMID: 34893795 DOI: 10.1093/ajcp/aqab192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/06/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The analytical sensitivity of high-sensitivity cardiac troponin T (hsTnT) assays has enabled rapid myocardial infarction rule-out algorithms for emergency department (ED) presentations. Few studies have analyzed the real-world impact of hsTnT algorithms on outcomes and operations. METHODS Comparison of ED length of stay (LOS) and 30-day outcomes (return to ED, inpatient admission, and mortality) for patients presenting with chest pain during 2 separate 208-day periods using a 0/1-hour hsTnT-enabled algorithm or fourth-generation TnT. RESULTS Discharge, 30-day readmission, and 30-day mortality rates were not significantly different with fourth-generation TnT vs hsTnT. Thirty-day return rates were significantly decreased with hsTnT (17.4% vs 14.9%; P < .01). For encounters with TnT measured at least twice and resulting in discharge, median ED LOS decreased by 61 minutes with the use of hsTnT (488 vs 427 minutes; P < .0001). Median time between first and second TnT results decreased by 82 minutes with hsTnT (202 vs 120 minutes; P < .0001), suggesting that the 0/1-hour algorithm was incompletely adopted. CONCLUSIONS Implementation of the hsTnT algorithm was associated with decreased 30-day return rates and decreased ED LOS for a subset of patients, despite incomplete adoption of the 0/1-hour algorithm.
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Affiliation(s)
- Nicholas J Bevins
- Department of Pathology, University of California San Diego, San Diego, CA, USA
| | - Hyojin Chae
- Department of Laboratory Medicine, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jacqueline A Hubbard
- Department of Pathology and Laboratory Medicine, Dartmouth University, Lebanon, NH, USA
| | - Edward M Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Vaishal M Tolia
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, CA, USA
| | - Robert L Fitzgerald
- Department of Pathology, University of California San Diego, San Diego, CA, USA
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Aloisio E, Chibireva M, Serafini L, Pasqualetti S, Falvella FS, Dolci A, Panteghini M. A Comprehensive Appraisal of Laboratory Biochemistry Tests as Major Predictors of COVID-19 Severity. Arch Pathol Lab Med 2020; 144:1457-1464. [PMID: 32649222 DOI: 10.5858/arpa.2020-0389-sa] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT.— A relevant portion of coronavirus disease 2019 (COVID-19) patients develop severe disease with negative outcomes. Several biomarkers have been proposed to predict COVID-19 severity, but no definite interpretative criteria have been established to date for stratifying risk. OBJECTIVE.— To evaluate 6 serum biomarkers (C-reactive protein, lactate dehydrogenase, D-dimer, albumin, ferritin, and cardiac troponin T) for predicting COVID-19 severity and to define related cutoffs able to aid clinicians in risk stratification of hospitalized patients. DESIGN.— A retrospective study of 427 COVID-19 patients was performed. Patients were divided into groups based on their clinical outcome: nonsurvivors versus survivors and patients admitted to an intensive care unit versus others. Receiver operating characteristic curves and likelihood ratios were employed to define predictive cutoffs for evaluated markers. RESULTS.— Marker concentrations at peak were significantly different between groups for both selected outcomes. At univariate logistic regression analysis, all parameters were significantly associated with higher odds of death and intensive care. At the multivariate analysis, high concentrations of lactate dehydrogenase and low concentrations of albumin in serum remained significantly associated with higher odds of death, whereas only low lactate dehydrogenase activities remained associated with lower odds of intensive care admission. The best cutoffs for death prediction were greater than 731 U/L for lactate dehydrogenase and 18 g/L or lower for albumin, whereas a lactate dehydrogenase activity lower than 425 U/L was associated with a negative likelihood ratio of 0.10 for intensive treatment. CONCLUSIONS.— Our study identifies which biochemistry tests represent major predictors of COVID-19 severity and defines the best cutoffs for their use.
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Affiliation(s)
- Elena Aloisio
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy (Aloisio, Chibireva, Serafini, Pasqualetti, Falvella, Dolci, Panteghini)
| | - Mariia Chibireva
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy (Aloisio, Chibireva, Serafini, Pasqualetti, Falvella, Dolci, Panteghini)
| | - Ludovica Serafini
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy (Aloisio, Chibireva, Serafini, Pasqualetti, Falvella, Dolci, Panteghini)
| | - Sara Pasqualetti
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy (Aloisio, Chibireva, Serafini, Pasqualetti, Falvella, Dolci, Panteghini)
| | - Felicia S Falvella
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy (Aloisio, Chibireva, Serafini, Pasqualetti, Falvella, Dolci, Panteghini)
| | - Alberto Dolci
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy (Aloisio, Chibireva, Serafini, Pasqualetti, Falvella, Dolci, Panteghini).,The Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy (Dolci, Panteghini)
| | - Mauro Panteghini
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy (Aloisio, Chibireva, Serafini, Pasqualetti, Falvella, Dolci, Panteghini).,The Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy (Dolci, Panteghini)
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McCarthy CP, Raber I, Chapman AR, Sandoval Y, Apple FS, Mills NL, Januzzi JL. Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays: A Practical Approach for Clinicians. JAMA Cardiol 2020; 4:1034-1042. [PMID: 31389986 DOI: 10.1001/jamacardio.2019.2724] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Traditionally, elevated troponin concentrations were synonymous with myocardial infarction. But with improvements in troponin assays, elevated concentrations without overt myocardial ischemia are now more common; this is referred to as myocardial injury. Physicians may be falsely reassured by the absence of myocardial ischemia; however, recent evidence suggests that myocardial injury is associated with even more detrimental outcomes. Accordingly, this article reviews the definition, epidemiology, differential diagnosis, diagnostic evaluation, and management of myocardial injury. Observations Current epidemiological evidence suggests that myocardial injury without overt ischemia represents about 60% of cases of abnormal troponin concentrations when obtained for clinical indications, and 1 in 8 patients presenting to the hospital will have evidence of myocardial injury. Myocardial injury is a concerning prognosis; the 5-year mortality rate is approximately 70%, with a major adverse cardiovascular event rate of 30% in the same period. The differential diagnosis is broad and can be divided into acute and chronic precipitants. The initial workup involves an assessment for myocardial ischemia. If infarction is ruled out, further evaluation includes a detailed history, physical examination, laboratory testing, a 12-lead electrocardiogram, and (if there is no known history of structural or valvular heart disease) an echocardiogram. Unfortunately, no consensus exists on routine management of patients with myocardial injury. Identifying and treating the underlying precipitant is the most practical approach. Conclusion and Relevance Myocardial injury is the most common cause of abnormal troponin results, and its incidence will likely increase with an aging population, increasing prevalence of cardiovascular comorbidities, and greater sensitivity of troponin assays. Myocardial injury represents a challenge to clinicians; however, given its serious prognosis, it warrants a thorough evaluation of its underlying precipitant. Future strategies to prevent and/or manage myocardial injury are needed.
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Affiliation(s)
- Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston.,Baim Institute for Clinical Research, Boston, Massachusetts
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Sakhnini A, Bisharat N. Practice behavior of emergency department physicians caring for patients with chest pain. Am J Emerg Med 2019; 37:1210-1212. [DOI: 10.1016/j.ajem.2018.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/23/2018] [Accepted: 11/24/2018] [Indexed: 10/27/2022] Open
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Kavsak PA, Andruchow JE, McRae AD, Worster A. Profile of Roche’s Elecsys Troponin T Gen 5 STAT blood test (a high-sensitivity cardiac troponin assay) for diagnosing myocardial infarction in the emergency department. Expert Rev Mol Diagn 2018; 18:481-489. [DOI: 10.1080/14737159.2018.1476141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James E. Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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Kavsak PA, Pardhan A, Krizmanich W, Worster A. Hospital Admission and Myocardial Injury Prevalence after the Clinical Introduction of a High-Sensitivity Cardiac Troponin I Assay. Clin Chem 2015; 61:1209-10. [DOI: 10.1373/clinchem.2015.243345] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine McMaster University
- Hamilton Health Sciences
| | - Alim Pardhan
- Hamilton Health Sciences
- Division of Emergency Medicine Department of Medicine McMaster University Hamilton, ON, Canada
| | - William Krizmanich
- Hamilton Health Sciences
- Division of Emergency Medicine Department of Medicine McMaster University Hamilton, ON, Canada
| | - Andrew Worster
- Hamilton Health Sciences
- Division of Emergency Medicine Department of Medicine McMaster University Hamilton, ON, Canada
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Ferraro S, Panteghini M. Laboratory medicine as the science that underpins medicine: the “high-sensitivity” troponin paradigm. ACTA ACUST UNITED AC 2015; 53:653-64. [DOI: 10.1515/cclm-2014-0812] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/03/2014] [Indexed: 01/10/2023]
Abstract
AbstractThe availability of so-called high-sensitivity troponin assays (hsTn) has scored a compelling goal for laboratory medicine, allowing the safe clinical application of international recommendations for the definition of acute myocardial infarction (AMI). However, the introduction of hsTn has not been welcomed by clinicians, claiming an increase in false-positive results. Here we critically trace back the steps following the introduction of hsTn by referring to the 5-year practical experience in our academic hospital and to suitable information available in the literature. In agreement with published data, we found that hsTn introduction was associated with an increased number of AMI diagnoses, whereas the test volume, the revascularization rate, and the proportion of cases with negative angiography findings remained virtually unchanged. Fast-track protocols for ruling out AMI have been further optimized to recommend sampling at presentation and after 3 h only. We focus on a cost-effective use of hsTn that can account for all clinical variables increasing the pre-test probability in order to ensure that tests are ordered only for patients at medium to high risk for acute coronary syndrome (ACS). To guide interpretation of results, hsTn typical release patterns suggestive for AMI should be identified by evaluating the significance of concentration changes. hsTn have markedly shortened the time to rule out or rule in AMI and has the potential to improve the prognostic assessment of critical patients in clinical contexts different from ACS.
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Scott IA, Cullen L, Tate JR, Parsonage W. Highly sensitive troponin assays — a two‐edged sword? Med J Aust 2012; 197:320-3. [DOI: 10.5694/mja11.11199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD
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Kavsak PA, Allen LC, Apple FS, Booth RA, Chan PC, Delvin E, Fraser A, Fu L, Gornall D, Collier C, Hill S, Hoffman B, Huang Y, Lavoie J, Lou A, Mattman A, McQueen M, Meng QH, Oleschuk C, Pudek M, Randell E, Sohn KY, Thorlacius L, Yip PM, Dahdah N, Devereaux P, Dhesy-Thind S, Hotte SJ, Worster A. Cardiac troponin testing in the acute care setting: Ordering, reporting, and high sensitivity assays—An update from the Canadian society of clinical chemists (CSCC). Clin Biochem 2011; 44:1273-7. [DOI: 10.1016/j.clinbiochem.2011.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 08/01/2011] [Indexed: 10/17/2022]
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Christ M, Bertsch T, Popp S, Bahrmann P, Heppner HJ, Müller C. High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department. ACTA ACUST UNITED AC 2011; 49:1955-63. [DOI: 10.1515/cclm.2011.695] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Indexed: 11/15/2022]
Abstract
AbstractEvaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introduction of high-sensitivity cTn assays substantially increases sensitivity to identify patients with acute MI even at the time of presentation to the emergency department at the cost of specificity. However, the proportion of patients presenting with cTn positive, non-vascular cardiac chest pain triples with the implementation of new sensitive cTn assays increasing the difficulty for the emergency physician to identify those patients who are at need for invasive diagnostics. The main objectives of this mini-review are 1) to discuss elements of disposition decision made by the emergency physician for the evaluation of chest pain patients, 2) to summarize recent advances in assay technology and relate these findings into the clinical context, and 3) to discuss possible consequences for the clinical work and suggest an algorithm for the clinical evaluation of chest pain patients in the emergency department.
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